State Medicaid, child welfare and mental health agencies currently confront a crisis regarding safe psychopharmacology for children in foster care. Estimated rates of psychotropic medication use for children in foster care are much higher (ranging from 13-52%) than those in the general youth population (4%). Safety concerns exist with regard to specific prescribing patterns among children in foster care, including: the increasing use of second-generation antipsychotics (SGA), the concomitant use of multiple psychotropic medications (i.e., 'polypharmacy') and psychotropic use among young children. In response, President Obama enacted legislation, building off of legislation passed in 2008, requiring states to develop a plan to oversee psychotropic use among children in foster care by June 30, 2012. While state agencies experimented with psychotropic oversight programs for children in foster care as early as the 1980s, scarce evidence exists as to the impact of these programs on psychotropic safety. This study proposes a national examination of state psychotropic oversight programs, both the policies (i.e., universal mental health evaluation, prior authorization, mandatory secondary opinion, and drug utilization reviews) adopted and organizational resources (i.e., interagency linkages and mental health expertise) deployed, to understand better whether these programs improve psychotropic safety. First, I will analyze results of a national web-based survey to determine the type of psychotropic oversight programs since 2002 in all 50 states (Aim 1). Specific attention will be given to the factors associated with the adoption of policy levers by 2007 (Aim 2). Employing a national Medicaid claims data, I will then examine state-level trends from 2002 to 2007 (inclusive) of four measures for psychotropic safety, specifically use of psychotropic medications, SGA use, polypharmacy, and use among young children (Aim 3). Based on theoretic sampling, I will purposively select four states that adopted psychotropic oversight policy levers between 2002 and 2007. A matched comparison of states without the policy innovation will be identified for each of the four states selected. Semi-structured qualitative interviews will be conducted with key informants from each of these eight states to examine policy levers and/or contextual factors potentially associated with any changes in psychotropic safety between 2002 and 2007 (Aim 4). A quasi-experimental pre-post design will then be conducted to assess the impact of the selected policy levers on psychotropic safety. Child, organizational, and state characteristics will be included in the model to assess the impact of these constructs on psychotropic safety, as compared to the matched comparisons. The dependent variables of interest will include measures of psychotropic safety. Difference-in-difference and random effects models will be used to estimate effects of the policy innovation on safety measures. In light of recent statutory requirements, this study will offer evidence to state Medicaid, child welfare, and mental health systems about the impact of psychotropic oversight programs on safety. PUBLIC HEALTH RELEVANCE: In response to rising public health concern around safe psychopharmacology for children, two federal statutory requirements, enacted in 2008 and in 2012, mandate that state child welfare agencies in concert with state Medicaid and public mental health agencies develop a psychotropic oversight program for children in foster care. The proposed study will (1) identify types of psychotropic oversight programs in place at the state level for children in foster care since 2002, (2) examine factors associated with the presence of a state psychotropic oversight policies by 2007, (3) describe trends in psychotropic medication rates among children in foster care nationally between 2002-2007 using Medicaid claims data, and (4) evaluate the impact of policy levers in four states, and four matched comparisons, on psychotropic safety for children in foster care. Given statutory requirements for the development of psychotropic oversight plans and the limited evidence of psychotropic oversight programs adopted prior to 2008, this study will inform policymakers, practitioners, and payers on the impact of psychotropic medication oversight programs (both policy levers and organizational resources) on psychotropic safety among this vulnerable population.